Updated Guidelines For Treatment Of Sexually Transmitted Diseases

The term STDs is used to refer to a variety of clinical syndromes caused by pathogens that can be acquired and transmitted through sexual activity.

The present guidelines represent an update of CDC’s 2006 recommendations, based on consultation with a group of experts knowledgeable in the area of STDs who were convened in Atlanta on April 18 to 30, 2009.

These guidelines were developed to offer recommendations for the treatment of persons who have or who are at risk for STDs, including human papillomavirus (HPV) infection and gonorrhoea, with updated information regarding the most effective treatment regimens, screening strategies, prevention, and vaccination schedules.

Prevention and control of STDs are based on 5 major strategies:

Educating and counseling persons at risk on strategies to reduce risk for STDs by changing sexual behaviors and using recommended prevention services;

Diagnosing asymptomatic infected persons and symptomatic persons who are unlikely to obtain diagnostic and management services;

Evaluating, treating, and counseling sex partners of persons infected with an STD; and

Pre-exposure vaccination of persons at risk for vaccine-preventable STDs.

Although HPV is the most prevalent STD, most infected individuals remain asymptomatic, and in 90% of cases, the infection resolves spontaneously within 2 years. In other cases, genital warts or cervical cancer may result, depending on the HPV strain. HPV testing can be incorporated into cervical cancer screening among women older than 30 years but is not recommended for women younger than 20 years or for men.

Updated information and recommendations in the new guidelines also include the following:

expanded diagnostic evaluation for cervicitis, including testing for C trachomatis and N gonorrhoeae by nucleic acid amplification, and testing for bacterial vaginosis (BV) and trichomoniasis;

new treatment recommendations for BV (metronidazole 500 mg orally twice a day for 7 days, or metronidazole gel 0.75%, 1 full applicator [5 g] intra-vaginally, once a day for 5 days, or clindamycin cream 2%, 1 full applicator [5 g] intravaginally, at bedtime for 7 days) and for genital warts (including waiting for spontaneous resolution, or podofilox 0.5% solution or gel, or imiquimod 5% cream, or sinecatechins 15% ointment);

the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications (for nongonococcal urethritis not caused by C trachomatis, single-dose azithromycin or doxycycline for 7 days, followed by single-dose metronidazole or tinidazole if symptoms persist);

lymphogranuloma venereum proctocolitis among men who have sex with men;

criteria for spinal fluid examination to evaluate for neurosyphilis;

emergence of azithromycin-resistant Treponema pallidum — azithromycin should not be routinely used to treat syphilis, which is still best treated with penicillin or with a 14-day course of doxycycline in penicillin-allergic patients;

recognition of an increased role for sexual transmission of hepatitis C, especially in individuals coinfected with HIV;

diagnostic evaluation after sexual assault by an experienced clinician in a manner that minimizes further trauma, with the decision to obtain genital or other specimens for STD diagnosis to be made on an individual basis;

prophylaxis and treatment after sexual assault including postexposure hepatitis B vaccination without hepatitis B immune globulin, and one-time antibiotic treatment with ceftriaxone or cefixime, metronidazole, and azithromycin; and

STD prevention approaches, including abstinence and reduction of number of sex partners, pre-exposure vaccination (including against hepatitis A and B), barrier methods, male circumcision, and high-intensity behavioral counseling for all sexually active adolescents and for adults at increased risk for STDs and HIV.

“These recommendations should be regarded as a source of clinical guidance and not prescriptive standards; health-care providers should always consider the clinical circumstances of each person in the context of local disease prevalence,” the guidelines authors write. “They are applicable to various patient-care settings, including family-planning clinics, private physicians’ offices, managed care organizations, and other primary-care facilities. These guidelines focus on the treatment and counseling of individual patients and do not address other community services and interventions that are essential to STD/human immunodeficiency virus (HIV) prevention efforts.”